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Committee Membership
• BRUCE (NED) CALONGE (Chair), The
Colorado Trust
• DAVID ABRAMSON, New York University
College of Global Public Health
• JULIE CASANI, North Carolina State
University
• DAVID EISENMAN, University of California,
Los Angeles
• FRANCISCO GARCIA, Pima County
• PAUL HALVERSON, Indiana University
• SEAN HENNESSY, University of Pennsylvania
• EDBERT HSU, Johns Hopkins University
• NATHANIEL HUPERT, Weill Cornell Medicine,
Cornell University
• REBECCA MAYNARD, University of
Pennsylvania
• SUZET MCKINNEY, Illinois Medical District
• JANE NOYES, Bangor University
• DOUG OWENS, Stanford University
• SANDRA QUINN, University of Maryland
• PAUL SHEKELLE, Southern California Evidence-
Based Practice Center, RAND Corporation
• ANDY STERGACHIS, University of Washington
• MITCH STRIPLING, Planned Parenthood Federation
of America
• STEVEN TEUTSCH, University of California, Los
Angeles, and University of Southern California
• TENER VEENEMA, Johns Hopkins University
• MATTHEW WYNIA, University of Colorado
Consultants to the Committee
PHEPR PRACTITIONERS
• JESSICA CABRERA-MARQUEZ, Puerto Rico
Department of Health
• CARINA ELSENBOSS, Public Health Seattle
and King County
• STEVEN HULEATT, West Hartford-
Bloomfield Health District
• CHRISTIE LUCE, Florida Department of
Health
• PATRICK LUJAN, Guam Department of
Public Health and Social Services
• DAVID NEZ, Navajo Department of Health
• PAUL PETERSON, Tennessee Department
of Health
• LOU SCHMITZ, American Indian Health
Commission for Washington State
• EDNA QUINONES-ALVAREZ, Puerto Rico
Department of Health
EVIDENCE REVIEW METHODOLOGY
• HOLGER SCHUNEMANN, McMaster
University
Charge to the Committee
• Develop the methodology for conducting a comprehensive review of
evidence for public health emergency preparedness and response
(PHEPR) practices, including the criteria by which to assess the
strength of evidence and a tiered grading scheme;
• Develop and apply criteria to determine which PHEPR capabilities
should be prioritized for inclusion in the comprehensive review;
• Apply the committee’s evidence review methodology to assess the
effectiveness of the selected practices;
• Develop recommendations for practices that communities, state,
territorial, local, and/or tribal agencies should or should not adopt,
based on evidence; and
• Provide recommendations for future research to address critical gaps,
as well as processes needed to improve the overall quality of evidence
within the field.
Key Terminology
• Public health emergency preparedness and response (PHEPR): The capability
of the public health and health care systems, communities, and individuals to prevent,
protect against, quickly respond to, and recover from health emergencies, particularly
those whose scale, timing, or unpredictability threatens to overwhelm routine
capabilities
• PHEPR practice: A type of process, structure, or intervention whose implementation
is intended to mitigate the adverse effects of a public health emergency on the
population as a whole or a particular subgroup within the population.
• Evidence-based interventions: Public health practices and policies that have been
shown to be effective based on evaluation research. Often, lists of evidence-based
interventions are identified through systematic reviews, but they sometimes need
adaptation to unique or varied settings, populations, or circumstances
• Mixed-method evidence synthesis: An evidence synthesis approach involving the
integration of quantitative, mixed-method, and qualitative evidence in a single review
Developing and Applying a PHEPR Evidence
Review and Evaluation Methodology
Overview of the Mixed-Method Review Process
1. Select the review topic, considering published literature on
gaps/priorities and stakeholder input.
2. Develop the analytic framework and key review questions in
consultation with appointed PHEPR practitioner consultants.
3. Conduct a search of the peer-reviewed and gray literature and
solicit papers from stakeholders.
4. Apply inclusion and exclusion criteria.
5. Separate evidence into methodological streams (quantitative
studies, including comparative, noncomparative, and modeling
studies, and descriptive surveys; qualitative studies; after action
reports [AARs]; and case reports) and extract data.
6. Apply/adapt existing tools for quality assessment of individual
studies based on study design.
Committee’s Systematic Review Topics
• Engaging with and training community-based partners (CBPs) to
improve the outcomes of at-risk populations after public health
emergencies (Community Preparedness Capability)
• Activating a public health emergency operations center (Emergency
Operations Coordination Capability)
• Communicating public health alerts and guidance with technical
audiences during a public health emergency (Information Sharing
Capability)
• Implementing quarantine to reduce or stop the spread of a contagious
disease (Non-pharmaceutical Interventions Capability)
Overview of the Mixed-Method Review Process
1. Select the review topic, considering published literature on
gaps/priorities and stakeholder input.
2. Develop the analytic framework and key review questions in
consultation with appointed PHEPR practitioner consultants.
3. Conduct a search of the peer-reviewed and gray literature and
solicit papers from stakeholders.
4. Apply inclusion and exclusion criteria.
5. Separate evidence into methodological streams (quantitative
studies, including comparative, noncomparative, and modeling
studies, and descriptive surveys; qualitative studies; after action
reports [AARs]; and case reports) and extract data.
6. Apply/adapt existing tools for quality assessment of individual
studies based on study design.
Example Analytic Framework: Engaging With and Training Community-
Based Partners to Improve the Outcomes of At-Risk Populations
Overview of the Mixed-Method Review Process
1. Select the review topic, considering published literature on
gaps/priorities and stakeholder input.
2. Develop the analytic framework and key review questions in
consultation with appointed PHEPR practitioner consultants.
3. Conduct a search of the peer-reviewed and gray literature and
solicit papers from stakeholders.
4. Apply inclusion and exclusion criteria.
5. Separate evidence into methodological streams (quantitative
studies, including comparative, noncomparative, and modeling
studies, and descriptive surveys; qualitative studies; after action
reports [AARs]; and case reports) and extract data.
6. Apply/adapt existing tools for quality assessment of individual
studies based on study design.
Mixed-Method Review Process Continued...
7. Synthesize the body of evidence within methodological streams
and apply an appropriate grading framework (GRADE for the
body of quantitative research studies and GRADE-CERQual for
the body of qualitative studies to assess the certainty of the
evidence [COE]/confidence in the findings, respectively).
8. Consider evidence of effect from other streams (e.g., modeling,
mechanistic, qualitative evidence, and AARs/case reports) and
support for or discordance with findings from quantitative
research studies to determine the final COE.
9. Integrate evidence from across methodological streams to
populate the PHEPR Evidence to Decision framework and to
identify implementation considerations.
10.Develop practice recommendations and/or implementation
guidance.
Framework for Integrating Evidence to Inform Recommendation
and Guidance Development for PHEPR Practices
Mixed-Method Review Process Continued...
7. Synthesize the body of evidence within methodological streams
and apply an appropriate grading framework (GRADE for the
body of quantitative research studies and GRADE-CERQual for
the body of qualitative studies to assess the certainty of the
evidence [COE]/confidence in the findings, respectively).
8. Consider evidence of effect from other streams (e.g., modeling,
mechanistic, qualitative evidence, AARs/case reports) and
support for or discordance with findings from quantitative
research studies to determine the final COE.
9. Integrate evidence from across methodological streams to
populate the PHEPR Evidence-to-Decision framework and to
identify implementation considerations.
10.Develop practice recommendations and/or implementation
guidance.
Systematic Review Results: Engaging With and
Training Community-Based Partners
Included Evidence Types: Quantitative comparative and noncomparative and
qualitative studies, case reports, surveys, parallel evidence (systematic reviews)
Key Findings: Culturally tailored preparedness training programs for CBPs and
at-risk populations they serve improve the PHEPR knowledge (moderate COE) and
preparedness behaviors (moderate COE) of trained at-risk populations.
Practice Recommendation (abbreviated): Engaging and training CBPs serving at-risk populations is recommended as part of
SLTT public health agencies’ community preparedness efforts so that those CBPs
are better able to assist at-risk populations they serve in preparing for and
recovering from public health emergencies. Recommended CBP training strategies
include
• the use of materials, curricula, and training formats targeted and/or
tailored to the individual CBPs and the at-risk populations they serve; and
• train-the-trainer approaches that utilize peer or other trusted trainers to
train at-risk populations.
Systematic Review Results: Engaging With and
Training Community-Based Partners
Implementation Guidance (abbreviated list):
• Ensure that multistakeholder collaborations with CBPs are diverse and
inclusive, with particular attention to those groups that are often
excluded and marginalized.
• Engage umbrella organizations (e.g., American Red Cross, United Way)
to reach smaller, local community-based organizations.
• Consider participatory engagement strategies that allow for ongoing,
bidirectional communication with CBPs to build trust and buy-in prior
to an emergency.
• Tailor the curriculum and format of CBP preparedness training
programs to the learning needs and preferences of specific audiences,
and ensure that they are culturally sensitive and appropriate.
• Consider soliciting stakeholder feedback in the evaluation of training
program materials and content.
Systematic Review Results: Activating an
Emergency Operations Center
Included Evidence Types: Qualitative studies, AARs, case reports
Insufficient Evidence Finding:Activating a public health emergency operations center (PHEOC) is a common
and standard practice, supported by national and international guidance and
based on earlier social science around disaster response. Despite widespread
use and minimal apparent harms, there is insufficient evidence to determine
whether activating a PHEOC and what specific components are or are not
effective at improving response. This does not mean that the practice does
not work or should not be implemented, but that more research and monitoring
and evaluation around how and in what circumstances a PHEOC should be
implemented are warranted before an evidence-based practice
recommendation can be made.
Systematic Review Results: Activating an
Emergency Operations Center
Implementation Guidance (abbreviated list):
Considerations for WHEN to activate public health emergency operations:
• A public health emergency is large in size and complex in scope
• A novel response may require multiple new tasks or partnerships
• An event occurs that requires public health support functions, large-scale
information sharing, or response coordination
• Resource, cost, technological, legal, and logistical constraints need to be
overcome
• An incident requires high levels of interagency partnership
Considerations for WHEN TO REFRAIN from activating public health emergency
operations (e.g., the cost of activating is higher than any potential resource
needs for the emergency)
Considerations for HOW to make the decision to activate public health
emergency operations (e.g., respect staff knowledge, and involve staff with
past emergency experience in leadership discussions)
Systematic Review Results: Communicating
Alerts and Guidance with Technical Audiences
Included Evidence Types: Quantitative comparative and qualitative studies,
surveys, AARs, case reports
Key Findings: Electronic messaging systems (e.g., email, fax, text) are
effective channels for increasing technical audiences’ awareness of public health
alerts and guidance during a public health emergency (moderate COE). Different
technologies have differing impacts; however, data are insufficient to conclude
what technology is best for which audiences in which scenarios.
Practice Recommendation: Inclusion of electronic messaging channels (e.g., email) is recommended as part
of SLTT public health agencies’ multipronged approach for communicating public
health alerts and guidance to technical audiences in preparation for and in
response to public health emergencies. The practice should be accompanied by
targeted monitoring and evaluation or conducted in the context of research when
feasible so as to improve the evidence base for strategies used to communicate
public health alerts and guidance to technical audiences.
Systematic Review Results: Communicating
Alerts and Guidance with Technical Audiences
Implementation Guidance (abbreviated list):
• Engage technical audiences in the development of communication
plans, protocols, and channels.
• Reduce message volume when feasible, and highlight new
information and any differences from previous or other existing
guidance.
• Develop distribution lists in advance of public health emergencies,
and ensure that contact information is kept up to date.
• Consider designating liaisons and institutional points of contact
and leverage existing networks (e.g., medical societies and
associations) to facilitate broad message dissemination.
Systematic Review Results: Quarantine
Included Evidence Types: Quantitative comparative and noncomparative,
modeling and qualitative studies, case reports, surveys, mechanistic evidence
Key Findings: There is high COE that quarantine can be effective in certain
circumstances, but evidence also points to substantial undesirable effects and
harms, including increased risk of infection in congregate quarantine settings
(high COE), psychological harms (moderate COE), and individual financial
hardship (high COE). Frequent and transparent risk communication/messaging
and access to employment leave may improve adherence to quarantine
(moderate COE).
Practice Recommendation: Implementation of quarantine by state, local, tribal, and territorial (SLTT)
public health agencies is recommended to reduce disease transmission and
associated morbidity and mortality during an outbreak only after consideration
of the best available science regarding the characteristics of the disease, the
expected balance of benefits and harms, and the feasibility of
implementation.
Implementation Guidance (abbreviated list):
Considerations for WHEN to implement quarantine:
Early in the outbreak, especially when there is a shortage or absence of
available medical countermeasures
Only after weighing the resources required against the expected benefits
The Ro is in a range in which quarantine can be expected to importantly
reduce transmission
Quarantine for durations commensurate with the expected duration of
asymptomatic infectiousness is feasible
Absence of or short asymptomatic infectious period
Considerations for HOW to implement quarantine (e.g., consider voluntary before
legally enforced quarantine, avoid congregate quarantine, consider the at-risk
populations, protection of civil rights and protection from avoidable harms)
Considerations for DURING and AFTER the implementation of quarantine (e.g.,
providing clear messaging on the rationale for quarantine and financial
compensation, food, and social and psychological support)
Systematic Review Results: Quarantine
A Broader View of the State of the Evidence
for PHEPR
Results from Commission Scoping Review and
Evidence Maps: Distribution by Capability
Results from Commission Scoping Review and
Evidence Maps: Distribution by Study Design
Results from Commission Scoping Review and
Evidence Maps: U.S. Impact Studies
Committee Conclusion on the State of PHEPR
Evidence
Overall, the committee concluded that the science
underlying the nation’s response to public health
emergencies is seriously deficient, hampering the
nation’s ability to respond to emergencies most
effectively to save lives and preserve well-being.
Improving and Expanding the Evidence Base
for PHEPR
RECOMMENDATION 1:
Appoint a PHEPR Evidence-Based Guidelines Group
CDC should appoint and support an independent group to develop
methodologically rigorous and transparent evidence-based
guidelines for PHEPR practices on an ongoing basis.
This group should take the methodology developed by the
committee as a starting point, but should also be charged with its
continued development.
The group should also identify and communicate key PHEPR
evidence gaps in annual reports to CDC and Congress to guide
future research on the effectiveness of PHEPR practices.
RECOMMENDATION 2:
Establish Infrastructure to Support Ongoing PHEPR Evidence
Reviews
CDC should establish the infrastructure, policies, and procedures
needed to ensure a sustained process for conducting and updating
evidence reviews and generating evidence-based practice
guidelines, in collaboration with other relevant federal agencies.
The infrastructure should include an open-access repository for
evidence-based PHEPR practices.
RECOMMENDATION 3:
Develop a National PHEPR Science Framework
To enhance and expand the evidence base for PHEPR practices and
translation of the science to the practice community, CDC should
work with other relevant funding agencies, SLTT public health
agencies, academic researchers, professional associations, and
other stakeholders to develop a National PHEPR Science
Framework so as to ensure resourcing, coordination, monitoring,
and execution of public- and private-sector PHEPR research.
RECOMMENDATION 3: Continued…
Build on and improve coordination,
integration, and alignment among
existing PHEPR research efforts and
ensure integration with the activities
of the PHEPR evidence-based
guidelines group proposed in
Recommendation 1.
Recognize and support PHEPR science
as a unique academic discipline.
Create a common, robust, forward-
looking PHEPR research agenda.
Support meaningful
partnerships between PHEPR
practitioners and researchers.
Prioritize strategies and mechanisms
for the translation, dissemination,
and implementation of PHEPR
research.
RECOMMENDATION 4:
Ensure Infrastructure and Funding to Support PHEPR Research
CDC, in collaboration with other relevant funding agencies, should
ensure adequate and sustained oversight, coordination, and
funding to support a National PHEPR Science Framework and to
further develop the infrastructure necessary to support more
efficient production of and better-quality PHEPR research. Such
infrastructure should include
sustained funding for practice-based and investigator-driven research;
support for partnerships (e.g., with academic institutions, hospital
systems, and SLTT public health agencies);
development of a rapid research funding mechanism and
interdisciplinary rapid response teams; and
enhanced mechanisms to enable routine, standardized, efficient data
collection with minimal disruption to delivery of services (e.g.,
preapproved, adaptable research and IRB protocols, a research arm
within the response structure).
RECOMMENDATION 5:
Improve the Conduct and Reporting of PHEPR Research
CDC, the Office of the Assistant Secretary for Preparedness and
Response (ASPR), the National Institutes of Health (NIH), the
Department of Homeland Security (DHS), the National Science
Foundation (NSF), and other relevant PHEPR research funders should
use funding requirements to drive needed improvements in the conduct
and reporting of research on the effectiveness and implementation of
PHEPR practices. Such efforts should include
• developing guidance on and incorporating into funding decisions the use of
appropriate research methods;
• establishing guidelines for evaluations using different designs, evidence
streams and concepts from emerging evaluation approaches, such as
complex intervention evaluations; and
• developing reporting guidelines, including essential reporting elements in
partnership with professional associations, journal editors, researchers, and
methodologists.
RECOMMENDATION 6:
Pursue Efforts to Further a Process of Quality Improvement to
Enhance the Quality and Utility of After Action Reports
CDC, in collaboration with ASPR and FEMA, should convene an expert
panel of relevant federal agencies, SLTT public health agencies, and
professional associations to advance a process for quality improvement
at the local, regional, state, and national levels to enhance the quality
and utility of AARs and support their use as sources of evidence for
evaluating the effectiveness of PHEPR practices. This process should
foster a culture of improvement in public health emergency response
and include, but not be limited to, discussions aimed at
• defining the essential core elements of a PHEPR AAR;
• establishing an independent review panel with a standardized after action
reporting process;
• establishing and maintaining a national repository of AARs; and
• exploring the privacy issues and the protection of information in AARs from
use in legal proceedings or in other punitive actions.
RECOMMENDATION 7:
Support Workforce Capacity Development and Technical Assistance
Programs for PHEPR Researchers and Practitioners
CDC and ASPR should work with professional and academic organizations
that represent multiple disciplines to guide and support the creation of
the workforce capacity development and technical assistance programs
necessary to ensure the conduct of quality PHEPR research and
evaluation and improve the implementation capacity of SLTT public
health agencies. Such efforts should include
• developing a research training infrastructure and career development grants;
• providing training grants for PHEPR researcher and practitioner teams;
• providing ongoing technical assistance and peer networking for both PHEPR
researchers and practitioners; and
• creating a training and certification program for CDC project officers and
state preparedness directors.
RECOMMENDATION 8:
Ensure the Translation, Dissemination, and Implementation of PHEPR
Research to Practice
CDC should use a coordinated implementation science approach to
ensure that the evidence-based practice recommendations resulting from
the PHEPR evidence-based guidelines group proposed in Recommendation
1 achieve broad reach and become the standard of practice of the target
audience. Strategies to this end include
incorporating evidence-based practices into the Public Health Emergency
Preparedness and Response Capabilities guidance document;
building evidence-based practices into the design of and funding decisions for
the PHEP Cooperative Agreement;
incentivizing and requiring SLTT public health agencies to test and evaluate
new or adapted practices and embed evaluations into routine operations;
disseminating evidence-based practices via CDC communication platforms
(e.g., MMWR) and those of partnering organizations (e.g., ASTHO, NACCHO);
leveraging PHAB accreditation and NACCHO’s Project Public Health Ready.
• The release of this report in the context of the COVID-19 pandemic
puts the challenges of limited research to support evidence-based
PHEPR practice in bold relief.
• The committee’s recommendations around adequate stable
funding, robust design and conduct of research studies,
development of the research workforce and programs, and a
commitment to collaboration between public health practitioners
and experienced researchers all are vital to ongoing support of the
knowledge development for and implementation of interventions
that will better protect the public’s health and minimize the
impact of the broad spectrum of emergencies that have and will
certainly continue to threaten the security of our nation.
Concluding Thoughts
Thank You!
CONTACT INFORMATION
Lisa Brown, Study Co-Director
202-334-2487 (office)
Autumn Downey, Study Co-Director
202-334-2046 (office)